Whipps Cross University Hospital
Requires improvement

Reports

Inspection carried out on 10-11 May 2017

During an inspection to make sure that the improvements required had been made

Whipps Cross University Hospital in Waltham Forest is part of Barts Health NHS Trust, the largest NHS trust in the country, serving 2.5 million people across Tower Hamlets and surrounding areas of the City of London and East London.

Whipps Cross University Hospital provides a range of general inpatient services with 586 beds, outpatient and day-case services, as well as maternity services and a 24-hour emergency department and urgent care centre. The hospital has various specialist services, including urology, ENT, audiology, cardiology, colorectal surgery, cancer care and acute stroke care.

This was a focused unannounced inspection to follow up on our previous inspection of Barts Health NHS Trust in July 2016 where we found a number of concerns around patient safety and the quality of care. At that time Whipps Cross University Hospital was rated overall inadequate.

We carried out an unannounced inspection between 10 and 11 May 2017 and inspected three core services: surgery, end of life care and outpatients and diagnostic imaging.

We found improvements in both end of life care and outpatients and diagnostic imaging, which have been reflected in the ratings. However, following concerns we found in surgery the ratings across each domain remain unchanged. We have written to the trust asking them to provide further information on how they are addressing the issues of poor care and treatment.

However, when considering the aggregated ratings across all eight core services, from both this inspection and last July, the hospital is now rated overall requires improvement.

Our key findings were as follows:

Safe

The hospital’s electronic incident reporting system was not always used effectively by staff to report, investigate and act upon incidents. Learning from incidents was not always identified or recorded. Feedback was not shared consistently with staff, as monthly ward meetings did not always take place.

Surgical site infection (SSI) data was not followed up and therefore the service did not know how many wound infections occurred after patients were discharged.

We observed a number of infection control issues related to the operating theatre environment including loose and exposed plaster on theatre walls and damaged flooring. Not all theatre areas had records of daily cleaning checks and some items of equipment labelled as clean had visible dust and/or damage. We did not see evidence of any theatre cleaning audits.

Not all staff had completed mandatory training.

The use of agency staff on some wards was high due to nursing staff vacancies. Nursing staff told us they were concerned about the quality of the agency nurses and gave us examples when this compromised patients' care and treatment.

We found there was a lack of working equipment available within the mortuary.

The environment of the in-patient diagnostic imaging area was poorly maintained.

Safety equipment was not always maintained or replaced to ensure the safety of patients or staff.

Effective

We did not see evidence of how national audit results were being used to drive local improvement programmes. The trust did not provide us with any action plans to demonstrate how national audit results were responded to.

Not all patients were screened for malnutrition as required by NICE guidelines. MUST compliance rates for surgical wards were still consistently below the trust target of 95%.

Patient outcomes were not being measured for patients receiving end of life or palliative care.

Caring

Most patients we spoke with told us their experiences of care were positive. We saw that staff treated patients with compassion and demonstrated a genuinely kind and caring attitude.

Responsive

Theatre cancellations were happening on the day of surgery due to lack of available beds and over-running and late starting theatre lists. Theatre utilisation rates had improved but were still below the trust’s target. Theatre lists were frequently delayed due to IT and equipment issues and last-minute list changes.

Bed shortages on wards meant recovery areas were regularly used to nurse patients overnight. Staff were concerned that patients’ needs were not being appropriately met.

Many patients were discharged out of hours (after 8pm) due to delays. The hospital did not carry out discharge audits and did not monitor their performance against the 48hr rapid discharge target for patients receiving end of life care.

Provisions for relatives who were at the hospital with their loved ones for long periods of time were not consistent and differed from ward to ward.

The availability of single rooms was at a premium in the hospital, which made dignified care for people at the end of their lives harder.

There were capacity issues in certain clinics and some clinics were cancelled due to lack of clinician availability.

Well-led

We saw limited evidence of improvements to the surgical service to make it safer for patients and more responsive to their needs. Many of the areas of concern highlighted during our last inspection still needed to be addressed by the service.

Governance systems were not always embedded in practice to provide a robust and systematic approach to improving the quality of services.

The risk register did not reflect all current risks to the service. Some risks had been on the register for several years and it was not clear when these had last been reviewed. The risk register did not show what controls were in place or actions taken to mitigate risks.

Staff we spoke with were not aware of a nominated non-executive director for end of life care, or of any representation at board level. There was a culture for end of life care in the hospital to be seen as the responsibility of the specialist palliative care team.

There was limited oversight of the extent or depth of potential patient harm as a result of a recent information technology systems failure.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

The trust must ensure governance systems are embedded in practice to provide a robust and systematic approach to improving the quality of services. This should capture relevant elements of good governance including an adopting a positive incident reporting culture where learning from incidents is shared with staff and embedded to improve safe care and treatment of patients.

The trust must improve bed management, theatre management and discharge arrangements to facilitate a more effective flow of patients across the hospital and to improve theatre cancellation and delayed discharge rates.

The trust must improve its referral to treatment time performance in line with national standards.

The trust must improve staff compliance with mandatory training including safeguarding training.

The trust must improve staff compliance and awareness of trust infection prevention and control policies and processes.

The trust must improve compliance with venous thromboembolism (VTE) assessments.

The trust must ensure all patients are screened for malnutrition as required by NICE guidelines.

The trust must ensure that patient records are stored securely in line with information governance standards.

The trust must ensure the hospital’s physical environment, including operating theatres, is fit for purpose and meets required standards.

The trust must continue to work towards improving the organisational culture to reduce instances of unprofessional behaviours

and bullying and ensure all staff feel sufficiently supported by their managers.

The trust must ensure there are sufficient numbers of qualified, skilled and experienced staff employed and deployed

to meet the needs of patients. This should include ensuring staff have the right skills to recognise and manage the

deteriorating patient.

The trust must ensure all staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.

The trust must ensure that risks to patient safety and service delivery are appropriately identified, recorded and escalated effectively.

The trust must ensure governance systems are embedded in practice to provide a robust and systematic approach to improving the quality of services.

The trust must ensure compliance with radiation protection regulations.

The trust must ensure that timely arrangements are in place to replace diagnostic imaging equipment identified as at risk of failure.

The trust must ensure there are functioning panic alarms across the outpatients department.

The trust must ensure that the environment is safe where children and young people are treated in adult clinics.

The trust must ensure that equipment used for moving deceased patients from the ward to the mortuary are properly maintained and suitable for the purpose for which they are being used.

The trust must ensure that systems and processes are in place to enable proper management and oversight of the mortuary and are understood by staff who provide mortuary duties out of hours and in the absence of regular staff from the outsourced third party.

The trust must have systems in place to assess and monitor their performance for rapid discharge and its effect on patient care.

The trust must assess the quality of services provided (including the quality of the experience of service users in receiving those services) in relation to its current palliative care consultant resource and with consideration to meeting the national guidance [‘Commissioning Guidance for Specialist Palliative Care: Helping to deliver commissioning objectives’ (Dec 2012.)] which recommends a minimum requirement of 1 whole time equivalent consultant in palliative medicine per 250 hospital beds. The hospital has 586 beds.

The trust must ensure that ward staff are provided with appropriate support and training in end of life and palliative care to enable them to carry out their role effectively.

In addition the trust should:

The trust should ensure staff always have access to reliable equipment to minimise potential delay to treatment.

The trust should ensure that timely arrangements are in place to replace ageing theatre equipment identified as at risk of failure.

The trust should ensure the needs and preferences of patients and their relatives are central to the planning and delivery of care at the hospital.

The trust should review, and take action to address, feedback from staff raised in the NHS staff survey.

The trust should act upon the results of national audits to address areas of poor performance and to help drive improvement in services.

The trust should ensure that surgical site infection (SSI) data is appropriately captured and reviewed.

The trust should ensure the safety of patients as they are transferred between CT and accident and emergency.

The trust should ensure training is provided for the role of chaperone.

The trust should ensure the physical environment is fit for purpose and maintained in a good state of repair.

The trust should ensure the business continuity plan is updated to reflect systems failures in outpatients and diagnostic imaging services.

The trust should ensure privacy for patients who attend the CT scanning unit.

The trust should ensure best practice around the use of appropriate interpreters.

The trust should ensure a consistent approach to sending reminders to patients about their appointments.

The mortuary audit from March 2017 reported on the age and number of the fridges available and recommended it for entry onto the trust risk register. The trust should ensure this issue is given proper consideration.

The trust should ensure that the second mortuary viewing room (in the accident and emergency department) is in a good state of repair.

The trust should ensure that the new clinical records system that contains mechanisms for patient outcome data to be collected is utilised. The outcome measures had been on the new system since March 2017. The SPCT had used it for a matter of weeks and were not yet in use.

The trust should ensure that work taking place to increase the limited multidisciplinary input in to the Margaret Centre and SPCT such as social work, therapy and psychological services, is continued.

The trust should ensure that it conducts a review regarding the inconsistency of provision available for relatives who were at the hospital with their loved ones for long periods of time. For instance, in relation to items such as tea and coffee, and for relatives staying overnight.

The trust should ensure that religious texts are readily available to patients of all major faiths who use the hospital.

The trust should ensure that information gathered from both ‘Have Your Say’ and the bereavement survey are used to improve care.

Professor Edward Baker

Chief Inspector of Hospitals

Download full report

During an inspection to make sure that the improvements required had been made

Whipps Cross University Hospital in Waltham Forest is part of Barts Health NHS Trust, the largest NHS trust in the country, serving 2.5 million people across Tower Hamlets and surrounding areas of the City of London and East London.

Whipps Cross University Hospital provides a range of general inpatient services with 586 beds, outpatient and day-case services, as well as maternity services and a 24-hour emergency department and urgent care centre. The hospital has various specialist services, including urology, ENT, audiology, cardiology, colorectal surgery, cancer care and acute stroke care.

This was a focused unannounced inspection to follow up on our previous inspection of Barts Health NHS Trust in July 2016 where we found a number of concerns around patient safety and the quality of care. At that time Whipps Cross University Hospital was rated overall inadequate.

We carried out an unannounced inspection between 10 and 11 May 2017 and inspected three core services: surgery, end of life care and outpatients and diagnostic imaging.

We found improvements in both end of life care and outpatients and diagnostic imaging, which have been reflected in the ratings. However, following concerns we found in surgery the ratings across each domain remain unchanged. We have written to the trust asking them to provide further information on how they are addressing the issues of poor care and treatment.

However, when considering the aggregated ratings across all eight core services, from both this inspection and last July, the hospital is now rated overall requires improvement.

Our key findings were as follows:

Safe

The hospital’s electronic incident reporting system was not always used effectively by staff to report, investigate and act upon incidents. Learning from incidents was not always identified or recorded. Feedback was not shared consistently with staff, as monthly ward meetings did not always take place.

Surgical site infection (SSI) data was not followed up and therefore the service did not know how many wound infections occurred after patients were discharged.

We observed a number of infection control issues related to the operating theatre environment including loose and exposed plaster on theatre walls and damaged flooring. Not all theatre areas had records of daily cleaning checks and some items of equipment labelled as clean had visible dust and/or damage. We did not see evidence of any theatre cleaning audits.

Not all staff had completed mandatory training.

The use of agency staff on some wards was high due to nursing staff vacancies. Nursing staff told us they were concerned about the quality of the agency nurses and gave us examples when this compromised patients' care and treatment.

We found there was a lack of working equipment available within the mortuary.

The environment of the in-patient diagnostic imaging area was poorly maintained.

Safety equipment was not always maintained or replaced to ensure the safety of patients or staff.

Effective

We did not see evidence of how national audit results were being used to drive local improvement programmes. The trust did not provide us with any action plans to demonstrate how national audit results were responded to.

Not all patients were screened for malnutrition as required by NICE guidelines. MUST compliance rates for surgical wards were still consistently below the trust target of 95%.

Patient outcomes were not being measured for patients receivingend of life or palliative care.

Caring

Most patients we spoke with told us their experiences of care were positive. We saw that staff treated patients with compassion and demonstrated a genuinely kind and caring attitude.

Responsive

Theatre cancellations were happening on the day of surgery due to lack of available beds and over-running and late starting theatre lists. Theatre utilisation rates had improved but were still below the trust’s target. Theatre lists were frequently delayed due to IT and equipment issues and last-minute list changes.

Bed shortages on wards meant recovery areas were regularly used to nurse patients overnight. Staff were concerned that patients’ needs were not being appropriately met.

Many patients were discharged out of hours (after 8pm) due to delays. The hospital did not carry out discharge audits and did not monitor their performance against the 48hr rapid discharge target for patients receiving end of life care.

Provisions for relatives who were at the hospital with their loved ones for long periods of time were not consistent and differed from ward to ward.

The availability of single rooms was at a premium in the hospital, which made dignified care for people at the end of their lives harder.

There were capacity issues in certain clinics and some clinics were cancelled due to lack of clinician availability.

Well-led

We saw limited evidence of improvements to the surgical service to make it safer for patients and more responsive to their needs. Many of the areas of concern highlighted during our last inspection still needed to be addressed by the service.

Governance systems were not always embedded in practice to provide a robust and systematic approach to improving the quality of services.

The risk register did not reflect all current risks to the service. Some risks had been on the register for several years and it was not clear when these had last been reviewed. The risk register did not show what controls were in place or actions taken to mitigate risks.

Staff we spoke with were not aware of a nominated non-executive director for end of life care, or of any representation at board level.There was a culture for end of life care in the hospital to be seen as the responsibility of the specialist palliative care team.

There was limited oversight of the extent or depth of potential patient harm as a result of a recent information technology systems failure.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

The trust must ensure governance systems are embedded in practice to provide a robust and systematic approach to improving the quality of services. This should capture relevant elements of good governance including an adopting a positive incident reporting culture where learning from incidents is shared with staff and embedded to improve safe care and treatment of patients.

The trust must improve bed management, theatre management and discharge arrangements to facilitate a more effective flow of patients across the hospital and to improve theatre cancellation and delayed discharge rates.

The trust must improve its referral to treatment time performance in line with national standards.

The trust must improve staff compliance with mandatory training including safeguarding training.

The trust must improve staff compliance and awareness of trust infection prevention and control policies and processes.

The trust must improve compliance with venous thromboembolism (VTE) assessments.

The trust must ensure all patients are screened for malnutrition as required by NICE guidelines.

The trust must ensure that patient records are stored securely in line with information governance standards.

The trust must ensure the hospital’s physical environment, including operating theatres, is fit for purpose and meetsrequired standards.

The trust must continue to work towards improving the organisational culture to reduce instances of unprofessional behavioursand bullying and ensure all staff feel sufficiently supported by their managers.

The trust must ensure there are sufficient numbers of qualified, skilled and experienced staff employed and deployedto meet the needs of patients. This should include ensuring staff have the right skills to recognise and manage thedeteriorating patient.

The trust must ensure all staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.

The trust must ensure that risks to patient safety and service delivery are appropriately identified, recorded and escalated effectively.

The trust must ensuregovernance systems are embedded in practice to provide a robust and systematic approach to improving the quality of services.

The trust must ensurecompliance with radiation protection regulations.

The trust must ensurethat timely arrangements are in place to replace diagnostic imaging equipment identified as at risk of failure.

The trust must ensurethere are functioning panic alarms across the outpatients department.

The trust must ensurethat the environment is safe where children and young people are treated in adult clinics.

The trust must ensure that equipment used for moving deceased patients from the ward to the mortuary are properly maintained and suitable for the purpose for which they are being used.

The trust must ensure that systems and processes are in place to enable proper management and oversight of the mortuary and are understood by staff who provide mortuary duties out of hours and in the absence of regular staff from the outsourced third party.

The trust must have systems in place to assess and monitor their performance for rapid discharge and its effect on patient care.

The trust must assess the quality of services provided (including the quality of the experience of service users in receiving those services) in relation to its current palliative care consultant resource and with consideration to meeting the national guidance [‘Commissioning Guidance for Specialist Palliative Care: Helping to deliver commissioning objectives’ (Dec 2012.)] which recommends a minimum requirement of 1 whole time equivalent consultant in palliative medicine per 250 hospital beds. The hospital has 586 beds.

The trust must ensure that ward staff are provided with appropriate support and training in end of life and palliative care to enable them to carry out their role effectively.

In addition the trust should:

The trust should ensure staff always have access to reliable equipment to minimise potential delay to treatment.

The trust should ensure that timely arrangements are in place to replace ageing theatre equipment identified as at risk of failure.

The trust should ensure the needs and preferences of patients and their relatives are central to the planning and delivery of care at the hospital.

The trust should review, and take action to address, feedback from staff raised in the NHS staff survey.

The trust should act upon the results of national audits to address areas of poor performance and to help drive improvement in services.

The trust should ensure that surgical site infection (SSI) data is appropriately captured and reviewed.

The trust should ensure the safety of patients as they are transferred between CT and accident and emergency.

The trust should ensure training is provided for the role of chaperone.

The trust should ensure the physical environment is fit for purpose and maintained in a good state of repair.

The trust should ensure the business continuity plan is updated to reflect systems failures in outpatients and diagnostic imaging services.

The trust should ensure privacy for patients who attend the CT scanning unit.

The trust should ensure best practice around the use of appropriate interpreters.

The trust should ensure a consistent approach to sending reminders to patients about their appointments.

The mortuary audit from March 2017 reported on the age and number of the fridges available and recommended it for entry onto the trust risk register. The trust should ensure this issue is given proper consideration.

The trust should ensure that the second mortuary viewing room (in the accident and emergency department) is in a good state of repair.

The trust should ensure that the new clinical records system that contains mechanisms for patient outcome data to be collected is utilised. The outcome measures had been on the new system since March 2017. The SPCT had used it for a matter of weeks and were not yet in use.

The trust should ensure that work taking place to increase the limited multidisciplinary input in to the Margaret Centre and SPCT such as social work, therapy and psychological services, is continued.

The trust should ensure that it conducts a review regarding the inconsistency of provision available for relatives who were at the hospital with their loved ones for long periods of time. For instance, in relation to items such as tea and coffee, and for relatives staying overnight.

The trust should ensure that religious texts are readily available to patients of all major faiths who use the hospital.

The trust should ensure that information gathered from both ‘Have Your Say’ and the bereavement survey are used to improve care.

Professor Edward Baker

Chief Inspector of Hospitals

Download full report

During a routine inspection

Whipps Cross University Hospital in Waltham Forest is part of Barts Health NHS Trust, the largest NHS trust in the country, serving 2.5 million people across Tower Hamlets and surrounding areas of the City of London and East London.

Whipps Cross University Hospital provides a range of general inpatient services with 636 beds, outpatient and day-case services, as well as maternity services and a 24-hour emergency department and urgent care centre. The hospital has various specialist services, including urology, ENT, audiology, cardiology, colorectal surgery, cancer care and acute stroke care.

Waltham Forest is in the most deprived quintile of local authority districts and about 25% of children (14,500) live in poverty. The population includes 47.8% BAME residents.

We returned to inspect this location (and the Royal London location) to follow up on our previous inspections of Barts Health NHS Trust in 2014 and 2015 where we found a number of concerns around patient safety and the quality of care. Following the last inspection, significant changes were made to the leadership of the organisation at both an executive and site level.

We carried out an announced inspection between 26 and 29 July 2016. We also undertook unannounced visits on 2 and 4 August 2016.

Overall, we rated this hospital as inadequate. The surgery and end of life care services were rated inadequate because of concerns around safety, responsiveness and leadership. We found important improvements had been made in maternity and gynaecology and services for young people since our last inspection. The other four core services were rated as required improvement.

Our key findings were as follows:

Safe:

There was no dedicated place of safety room in the emergency department for patients with psychiatric conditions.

Infection prevention and control procedures were not strictly adhered to, increasing the risk of infection for patients. We found poor infection control practice in the surgery service.

The incident reporting process was inconsistently applied. We found limited evidence of learning from incidents or complaints.

Staff did not always record actions taken or learning points for incidents. The knowledge of incidents and awareness of shared learning was inconsistent.

The trust did not provide all patients with one-to-one care during labour which is recommended by the Department of Health.

Staff had a good understanding of the trust's safeguarding policy and procedures and how to protect patients from abuse. The children’s service had good arrangements in place to keep children and young people safe.

Effective:

The use of clinical audits was inconsistent across the core services. We found that some services were undertaking little auditing to identify improvements they could make to patient care.

We found that there was good compliance with local and national guidance in the treatment of patients.

The hospital participated in the National Care of the Dying Audit in May 2015 and in 2016. The hospital performed worse than the England average in most areas for both audits. The service had been slow to start actions and make changes to improve end of life care for patients.

Caring:

Most staff were caring and compassionate in their delivery of care.

Most patients and relatives we spoke with were satisfied with the care and support they received and felt that staff took the time to include them in decisions about their care.

We found many examples of a lack of compassion towards patients nearing the end of their lives.

Responsive:

Emergency department performance against the national four hour target for treatment and discharge was well below the national 95% target at around 85%.

The trust suspended monthly mandatory 18-weeks referral to treatment time (RTT) reporting from September 2014 onwards. This followed the identification of significant data quality concerns relating to the accuracy, completeness and consistency of the RTT patient tracking list.

The average length of stay at Whipps Cross University Hospital was in line with the England average for both elective and non-elective admissions.

At trust level the percentage of patients whose operations were cancelled and not treated within 28 days was worse than the England average between the first quarter of 2013/14 to quarter four of 2015/16. However, this had improved from around 30% in quarter three of 2014/15 to around 10% in quarter four of 2015/16.

Well led:

Changes to the leadership structure of the trust, including at site level, were beginning to make a positive impact on the improvement of standards but the pace was too slow. Most staff spoke optimistically of the new leadership structure.

Governance and risk management was generally well managed. We observed many good managers who had a clear understanding of the issues they faced in their service areas.

In some services there was a lack of understanding of the vision and strategy of the whole organisation. Local hospital plans and visions were generally well understood.

We found pockets of poor culture with evidence of bullying and inequality.

We were unable to find any areas of outstanding practice at Whipps Cross Hospital.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

The trust must improve bed management, theatre management and discharge arrangements to facilitate a more effective flow of patients across the hospital and to improve theatre cancellation and delayed discharge rates. This should include improving flow of patients into and out of critical care.

The trust must improve compliance and awareness of trust infection prevention and control policies and processes to ensure surgical staff do not wear theatre scrubs and clogs outside the operating theatres. Additional, the trust should review its infection control policies for ensuring infectious patients are effectively and safely managed in ward areas.

The trust must improve compliance with venous thromboembolism (VTE) assessments.

The trust must work towards improving the organisational culture to reduce instances of unprofessional behaviours and bullying and ensure all staff feel sufficiently supported by their managers.

The trust must ensure all patients are treated in a caring and compassionate manner, and ensure their privacy and dignity is maintained.

The trust must ensure that patients' pain levels are monitored and acted on appropriately and that pain relief is provided to patients when required.

The trust must ensure there are sufficient numbers of qualified, skilled and experienced staff employed and deployed to meet the needs of patients. This should include ensuring staff have the right skills to recognise and manage the deteriorating patient.

The trust must ensure all staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.

The trust must ensure governance systems are embedded in practice to provide a robust and systematic approach to improving the quality of services. This should capture relevant elements of good governance including an adopting a positive incident reporting culture where learning from incidents is shared with staff and embedded to improve safe care and treatment of patients.

The trust must ensure staff on the wards receive sufficient handover including patients' infectious status.

The trust must ensure all patients are screened for malnutrition as required by NICE guidelines.

The trust must ensure that patients needing urgent referrals or follow up appointments for assessment or treatment are followed up promptly.

In addition the trust should:

The trust should improve its performance against the national four hour target for treatment and admission/discharge in ED.

The trust should ensure staff always have access to reliable equipment to minimise potential delay to treatment.

The trust should ensure mixed-sex accommodation breaches are reported without any delays and as required by NHS England guidance.

The trust should consider the use of an acuity tool to manage capacity on delivery suite.

The trust should ensure that the latest version of the 'Do Not Attempt Cardio Pulmonary Resuscitation' (DNACPR) forms are used throughout the hospital.

The trust should improve access to chaplaincy service to meet people’s spiritual and emotional needs.

The trust should ensure the needs and preferences of patients and their relatives are central to the planning and delivery of care at the hospital.

The trust should ensure the physical environment is fit for purpose,

The trust should ensure children with learning disabilities are identified on presentation to the hospital and facilities to support these children improved.

The trust should ensure patients are fully involved in decisions about their care and treatment.

The trust should ensure that records are complete, accurate and do not contain variances and discrepancies.

The trust should improve the availability of medical records and reduce the requirement for the need for temporary notes.

The trust should implement a systematic approach to the assessment of individual risks to the health, safety and welfare of patients.

The trust should review medical staffing at night in medical services and nurse staffing on acute assessment unit.

The trust should ensure care plans reflect the individual needs of patients, with particular focus on those with complex needs.

The trust should ensure compliance with the Mental Capacity Act (2005) and Deprivation of Liberty safeguards (DoLS).

The trust should ensure more patients are clinically assessed within the 15 minute national target.

Download full report

During a routine inspection

Whipps Cross University Hospital is part of Barts Health NHS Trust and provides acute services to a population of approximately 350,000 living in Waltham Forest and surrounding areas of East London and Essex.

The trust employs around 15,000 whole time equivalent (WTE) members of staff with approximately 836 nursing and midwifery staff working at Whipps Cross University Hospital.

We inspected this location as a direct response to concerns raised from a number of sources, stakeholders, patients, local politicians and indicators which we consistently monitor. We spoke with over 185 patients and relatives, and 400 members of staff.

Overall, we rated this hospital as 'inadequate'. We found urgent and emergency care, medical care (including care for older people), surgery, services for children and young people, outpatients and diagnostic imaging and services for those patients requiring end of life care were inadequate. Significant improvements are required in these core services.

We found that maternity and gynaecology and critical care require improvement.

We rated this hospital as inadequate for safe, effective, responsive and well-led and rated caring

as requires improvement.

Our key findings were as follows:

There was a culture of bullying and harassment and we have concerns about whether enough is being done to encourage a change of culture to be open and transparent.

Morale was low. Some staff were reluctant to speak with the inspection team, when staff did some did not want the inspection team to record the discussions in fear of repercussions.

The decision in 2013 to remove 220 posts across the trust and down band several hundred more nursing staff has had a significant impact on morale and has stretched staffing levels in many areas. We observed the reorganisation had a damaging impact on staff and the service provided.

Staffing was a key challenge across all services and the environment was not conducive to recruitment and retention and the sustainability of services.

The implementation of IT systems had impacted on patient safety and care. The trust recognised there had been issues and were attempting to resolve them. However patients were struggling to get appointments and be recognised as needing care and treatment.

Patients, staff and stakeholders including Commissioners, MPs, Royal Colleges, Health Education England and local branches of h

Healthwatch continue to raise concerns about the quality of the service provided.

Safe:

There were not enough nursing and medical staff to ensure safe care was provided.

Handovers between medical staff were unstructured and did not ensure relevant staff were aware of specific patient information or the wider running of the hospital.

There was limited learning from incidents. Staff did not have the time to report incidents, were not encouraged to report incidents and were not aware of any improvements as a result of learning from these incidents. Some senior staff were unaware of serious incidents and action plans that involved them leading the required change.

There were low levels of compliance with mandatory training. It was not always evident that learning from the training was embedded.

Medicines management required improvement in some areas including, but not limited to the storage and administration of medicines. There was an inconsistent use of opioids across wards.

Patients nearing the end of their life were not identified, and their needs therefore were not always assessed and met.

The application of early warning systems to assist staff in the early recognition of a deteriorating patient was varied. The use of an early warning system was embedded within the surgery, while in A&E and medical care areas, its use was inconsistent. the National Early Warnings System had not yet been implemented in the hospital.

Theatre ventilation was not adequately monitored.

Effective:

The use of national clinical guidelines was not evident throughout the majority of services. An end of life pathway to replace the existing Liverpool Care Pathway had not been introduced. National guidance for the care and treatment of critically ill patients was not always followed.

Medical patients pain relief was managed.

The management of patients nutritional and hydration needs varied. In the National Care of the Dying Audit patient’s' nutrition and hydration requirements being met was rated worse than the England average.

Patient outcomes in national audits were similar to or below the performance of other hospitals.

We were told that actions had been taken to raise staff awareness of the Mental Capacity Act 2005 and deprivation of liberty safeguards. Records showed mental capacity was recorded and families were involved however we found most staff we spoke with lacked an understanding of the Mental Capacity Act and deprivation of liberty safeguards.

The trust was working towards seven day working. Job planning for medical staff had started. Access to fundamental diagnostic and screening tests out of hours was limited. There was no critical care outreach team after 5pm or at weekends.

Caring:

Improvements were required to ensure staff were always caring and compassionate and treated patients with dignity and respect at all times.

In September 2014, 194 of 210 (92%) respondents to the friends and family test were 'extremely likely' or 'likely' to recommend the inpatient service.

Responsive:

The average bed occupancy for from May to October 2014 was 91%. This impacted on the flow of patients throughout the hospital. Patients were cared for in recovery, or transferred out of critical care for non clinical reasons.

Patients well enough to leave hospital experienced significant delays in being discharged because of documentation needing to be completed. During our inspection an estimated 30 patients were well enough to leave hospital but remained because their continuing health care assessments had not been completed. Staff that previously completed this paperwork were no longer in post because of the restructure.

Operations were often cancelled due to a lack of available beds.

The average length of stay (ALOS) was high, the trust recognised this issue was impacting on patient care and had taken some action to address it.

The hospital was persistently failing to meet the national waiting time targets. Some patients were experiencing delays of more than 18 weeks from referral to treatment (RTT). The trust had suspended reporting activity to the department of health and had started a recovery plan.

Many patients experienced delays in their treatment as a result of lack of planning to introduce the electronic patient records system or when transport arrangements had changed. Patients complained that they were unable to get in touch with the hospital.

Capacity issues within the hospital led to a high proportion of medical “outliers” (patients on wards that were not the correct specialty for their needs) . The result of this was that patients were being moved from ward to ward on more than one occasion, this impacted on their treatment, delayed their stay in hospital and were on occasion transferred late at night.

Well-led:

Staff told us that the executive team were not visible.

Morale was low. The 2013 NHS Staff Survey for the trust as a whole had work related stress at 44%, the joint highest rate in the country for an acute trust. 32% recommend it as a place to work, which is third lowest in the country.

Nursing staff who were previously supernumerary to the shift were no longer there to provide leadership and guidance.

There were a number of vacant managerial posts and interim staff in post making it difficult for staff to be well-led.

The application of clinical governance was varied, with some services lacking any formal, robust oversight. Risk registers were poorly applied in some clinical areas which led to some risks not being recorded and or escalated.

The trust was £13.3 million off its financial plan at the end of September 2014, the year end forecast outturn was revised from £44.8 million to a deficit of £64.1 million. £2 million additional costs were specifically associated with the deployment of IT systems at Whipps Cross University Hospital as the deployment had been unsuccessful and it had been necessary to invest significant resources to address problems in outpatients booking and scheduling.

We saw some areas of outstanding practice including:

Pain relief for children and adults was effectively managed.

The Great Expectations maternity programme had led to a reported better experience for women. There had been a reduction in complaints regarding staff behaviour and attitude and an increase in women's satisfaction of the maternity service.

However, there were also areas of poor practice where the trust needs to make improvements.

The hospital must ensure:

Safety and effectiveness are a priority in all core services

Services are be well-led.

Adequate steps are taken to meet the fundamental needs of patients.

There are appropriate levels and skills mix of staffing to meet the needs of all patients.

Bank and agency staff are fully inducted to ensure they can access policies, be aware of practices and provide care and treatment in the areas they are required to work in.

Complaints are investigated in a timely manner and patients are involved and action taken.

Robust assessment and monitoring of the quality of the service.

Patients leave hospital when they are well enough. Average length of stay was higher than medically necessary.

Procedures for documenting the involvement of patients, relatives and the multi-disciplinary team ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNA CPR) forms are followed at all times.

Accurate records are available for the majority of patients attending outpatient appointments.

Safeguarding procedures are improved and followed.

All staff understand the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Equipment is ready for use and appropriately maintained.

The environment is adequately maintained to protect patients.

Medications are stored safely.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During a routine inspection

Whipps Cross University Hospital is in Leytonstone, east London, and serves 350,000 people in Waltham Forest, Redbridge, Epping Forest and other areas. It provides a full range of inpatient, outpatient and day case services as well as maternity and accident and emergency departments. The hospital serves an area with a wide variation in levels of deprivation and health needs, ranging from the most deprived 5% to among the most affluent 30% of electoral wards in England.

Whipps Cross University Hospital is part of Barts Health NHS Trust, the largest NHS trust in England. It has a turnover of £1.25 billion, serves 2.5 million people and employs over 14,000 staff. The trust comprises 11 registered locations, including six primary hospital sites in east and north east London (Mile End Hospital, Newham University Hospital, St Bartholomew’s Hospital, The London Chest Hospital, The Royal London Hospital and Whipps Cross University Hospital) as well as five other smaller locations.

CQC has inspected Whipps Cross Hospital four times since it became part of Barts Health on 1 April 2012. Our most recent inspections were in May and June 2013, when we visited the A&E and maternity departments, outpatients, surgery services and care of the elderly wards. We issued three warning notices to the trust relating to infection control, safety and availability of equipment and supporting its workers. We also issued compliance actions.

We had significant concerns about the quality and safety of care in certain areas of the hospital. As part of this inspection, we checked whether the trust had addressed some of these shortfalls, and we took a broader look at the quality of care and treatment in a number of departments.

Our inspection team included CQC inspectors and analysts, doctors, nurses, midwives, allied health professionals, patient ‘Experts by Experience’ and senior NHS managers. We spent three days visiting the hospital. We spoke with patients and their relatives, carers and friends, and hospital staff. We observed care and inspected the hospital environment and equipment. We held two listening events in Leyton and Walthamstow and heard directly from people about their experiences of care. Before the inspection we also spoke with local bodies, such as clinical commissioning groups, local councils and Healthwatch.

We found some good areas of practice and many positive findings. Patients held staff in high regard and felt them to be committed, compassionate and caring. Our observations confirmed this. The intensive care unit (ICU) was safe, met patients’ needs and demonstrated how improvements could be made through learning from incidents. Improvements have been made in both accident and emergency and maternity services since our last inspection, and we saw some good practice in these departments. Palliative care was compassionate and held in high regard by staff, patients and their friends and family. We saw some good practice in children’s services. The hospital was clean and staff adhered to good infection control practice. Staff worked well together in multidisciplinary teams.

However, a number of improvements need to be made. Prompt action is required in some areas of the hospital to ensure that care and treatment is safe and responds to people’s needs. Work is also needed to make sure the hospital functions effectively and to improve leadership and morale.

Staffing levels on the medical and surgical wards need to be increased to ensure patients’ medical and other needs are met. The hospital also needs to ensure that staff have access to the appropriate equipment.

The trust needs to make radical improvements to patient flow and discharge arrangements. Too many patients had to wait to be discharged or were delayed in other parts of the hospital. This impacted on the effective functioning of the hospital.

Equipment in parts of the hospital was either unavailable, in short supply, inappropriate or not subject to the appropriate checks. Some of this equipment was essential.

The hospital environment was satisfactory, although improvements need to be made to the some wards, the Margaret Centre and outpatients so that patients’ needs can be met and their privacy and dignity can be maintained.

Patients need to be made aware of how to make a complaint and the hospital needs to improve how it learns from complaints. In addition, the hospital’s risk register needs to be more actively managed.

While some areas of the trust were well-led, some wards needed stronger leadership and better support from the hospital. The governance of the hospital needs to be improved so that staff are empowered to make decisions and know how to make changes or get problems solved. We recognise that the trust has started to make changes, although these need time to become effective.

Staff culture was not sufficiently open and some staff felt inhibited in raising concerns. Morale was low across all staffing levels and some staff felt bullied.

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During a routine inspection

Emergency Department

Patients were spending too long in the emergency department at Whipps Cross University Hospital. The nationally agreed target is that 95% of patients should be seen within four hours. However, the hospital had not met this target since November 2012. Between January and March 2013 there had been 31 occasions when patients had to wait more than 60 minutes from the time the ambulance arrived at hospital until both clinical and patient handover was completed, although we were told that emergency attention was provided on the trolley when required. This meant ambulance patients were waiting longer to be seen.

During the inspection we found that some patients had to wait longer than they should expect. Walk in patients were seen promptly for an initial assessment, but the time to treatment and consultant sign off were inconsistent. One patient in particular had to wait over four hours to be admitted and there was some confusion about this patient’s referral.

We were concerned that some patients who had been in the emergency department for prolonged periods of time were not always offered adequate nutritional support.

Elderly Care

Patients did not always receive appropriate care and treatment and staffing arrangements were sometimes deficient. On a number of occasions we found that there were not enough staff on duty. On the day of our visit, two wards were short by one qualified nurse. There were inadequate arrangements in place when key staff members were absent for a long period of time.

Care plans were not always updated as people’s needs changed. Risk assessments for falls, moving and handling and Malnutrition Universal Screening Tool (MUST) were used but not always reassessed. We found that there had been a number of falls on one ward and there were five hospital acquired pressure sores on two wards. Essential checks for patients with naso-gastric tubes were not carried out and this was not in line with the trust’s policy.

Patients sometimes had to wait to get support to eat their meals. We observed that some patients were not helped to eat when they needed it and that although they were given water, it was sometimes placed out of their reach.

The elderly care department did not have enough equipment which meant that some wards had to share equipment.

At our last inspection in November 2012, we found that appraisals, supervision and team meetings for nursing staff were inconsistent. At this inspection we found that the support provided to staff was inadequate. Some staff had not had an appraisal for over a year. Staff meetings were irregular and supervision was mainly informal, inconsistent and not recorded. We found that there were inadequate arrangements in place to ensure that appraisals and supervision continued in the absence of key staff.

Outpatients

Patients were provided with appropriate information and involved in their care. Their diversity, values and human rights were respected.

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During an inspection in response to concerns

We inspected maternity and surgery services at Whipps Cross hospital and found evidence that essential standards of care were not being met. We found evidence of care that was not safe, effective or responsive to people’s needs. We saw examples of people being treated in an uncaring way.

We saw examples of poor care, unacceptable staff behaviour and poor infection control in maternity services. In surgery, theatre processes and communication arrangements put people’s safety at risk. Surgery and maternity were both too busy, did not have enough staff to look after people’s needs, and lacked bed capacity, which meant they were not as effective as they should be and not always responsive to people’s needs.

The management at Whipps Cross are not adequately managing risks in either maternity or surgery. As a result of one inspection in maternity and surgery, we identified serious shortfalls in eight of the 16 essential standards which all hospitals are required by law to comply with. The trust has failed to identify and take action to address some of these shortfalls. Urgent action needs to be taken by the trust to ensure that the care provided to people improves and that the hospital management and systems to monitor the quality and safety of care are effective.

Maternity services

We found serious shortfalls on the maternity department. Some emergency neo-natal resuscitation equipment had not been checked which could result in the delay of care to a new born baby in an emergency if found to be faulty. Women and babies were not protected from the risk of infection. The wards were unclean in places, poorly maintained and needed repairing. Infection control practice amongst staff was poor on occasions.

Some staff failed to be compassionate and caring. Women’s confidentiality was sometimes compromised by staff. Records were inaccurate and did not always reflect women’s current health status.

Sometimes, there were not enough beds in the maternity department.This resulted in the ward occasionally shutting and women in labour being re-directed to another London hospital not of their choice. There was not always a doctor available in the triage area of the labour ward. This meant some women waited up to four hours to be seen.

Surgical services

There were not enough staff on duty on two wards. This led to people receiving unacceptable levels of care. One person had wet the bed because staff were unable to get to them in time due to their workload.

There were not enough beds available for people. This meant that people waited too long in the recovery areas after surgery while staff attempted to find a bed. Operations were often cancelled because of bed shortages. People were having poor outcomes after surgery as the 90 day post-surgery mortality rate was higher than the national average. Following a series of never events in surgery, we found that action had been taken to improve safety. However, further work needed to be done.

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During a routine inspection

We looked at care on the emergency department and on three elderly medicine wards. We observed that patients were spoken to in a respectful manner. A relative on the emergency department said, “we have been here for three hours. Staff have been brilliant. They have tried to answer all our questions.”

Care was assessed and planned according to patients needs. Appropriate risk assessments were used. We found staff had up to date training on resuscitation. Resuscitation trolleys were checked regularly. However we found two oxygen cylinders that had not been serviced on their due dates of 31/10/2012 and 30/06/2012.

Patients were cared for in a clean and hygienic environment. We found that clinical waste and soiled linen was disposed of appropriately. Hand gel dispensers were available and sinks were located next to hand wash, paper towels and bins. However, sharps bin were sometimes overfilled.

Staff told us that they were appraised yearly and we saw documentary evidence of appraisals. On the emergency department, team meetings and supervision were happening regularly. However on the three wards frequency of staff meetings and supervision varied.

Staff said they would try to resolve complaints at ward level. If this failed they would refer people to the Patient Advice Liaison Service. We found that complaints were responded to in an appropriate manner. Leaflets on how to make complaints were not readily available on two wards and the emergency department.

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During an inspection in response to concerns

We visted Beech Ward, an elderly care ward, following allegations of abuse that had been disclosed to the hospital through their whistleblowing procedure. The hospital reported to us that it had taken measures and actions to ensure that people were protected from the risk of further harm and that the allegations were being properly investigated.

This visit took place to ensure that people were being protected from harm and to look at the trust's immediate response to the disclosure.

People who use the service told us that the care and treatment they had received had been good and people were complimentary about the service they had received from nurses. We were told that nurses responded to buzzers in a timely manner and that people’s needs were being met. One person told us that communication could be better with the medical staff who had not spoken to the family about their relative’s health issues.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.